Pulmonary Disease 9% Flashcards
Obstructive dz (dilated)
COPD, Bronchiectasis
Obstructive (constricted)
Asthma
Intrathoracic Restrictive (constricted)
Fibrosis, Sarcoidosis, pneumoconiosis
Extrathoracic Restrictive
Chest Cage: kyphosis, spondylitis, obesity.
neuromuscular: (M.gravis, GB syndorme, muscular dystrophy
Normal FEV1/FVC
> 80%
Obstructive dz FEV1/FVC
<80%
Restrictive dz FEV1/FVC
> 80%
COPD
- dec FEV1,
- dec FEV1/FVC ( <80%),
- inc TLC, (#1..first thing you look at, best test restrict vs obstruct)
- dec DLCO, (#2..2nd thing you look at)
- inc RV
Asthma
- dec FEV1,
- dec FEV1/FVC,
- inc TLC,
- normal/increased DLCO, **
- inc RV
Restrictive intrathoracic
- dec FEV1,
- nl FEV1/FVC,
- dec TLC,
- dec DLCO, **
- dec RV **
Restrictive extrathoracic
- dec FEV 1,
- nl FEV1/FVC,
- dec TLC,
- nl DLCO, **
- inc RV **
best test restrictive vs obstructive
TLC
DLCO 140% predicted, normal FEV1/FVC and TLC. most likely finding of …
alveolar hemorrhage
Inc DLCO
CHF, MS, ASD/VSD, PDA, polycythemia, asthma, squatting, exercise, alveolar hemorrhage.
any reason for increased blood to pulmonary vasculature.
Dec DLCO
COPD, restrictive lung dz, PE, PHTN, anemia, standing, valsalva.
anything impeding the flow of blood in thoracic cavity
Normal DLCO
asthma, CO poisoning
Fixed extrathoracic
tumors/tracheal stenosis….. both inspiratory (bottom) and expiratory (top) loops blunted….. confirm w/ bronch
Dynamic extra-thoracic obstruction
epiglottis, Vocal cord dysfxn (inspiratory - bottom loops blunted) … confirm w/ laryngoscopy.
Dynamic intra-thoracic obstruction
intrathoracic tracheomalacia - exhalatory (upper) loop blunted
Asthma
- Paroxysmal
- Inflammatory
- Nonspecific reactive airway disease.
reactive to: dust, viral infection, cold or exercise, occupasional allergens: isocyanates (urethane paint), cotton dust (byssinosis), wood dust (cedar or oak), metal workers.
- usually present with a combination of symptoms.
- chronic cough –> SOB –> wheeze.
If pt has asthmatic symptoms (cough, SOB, wheeze)… what is the next diagnistic step?
PFT’s show –> obstructive changes with reversible broncospasm - responding to bronchodilators by increasing FEV1 by about 12%), then asthma is diagnosed.
- if no obst, but clinical suspicion is high, then methacholine challenge test to provoke bronchospasm and should respond to bronchodilator by about 12% increase in FEV1
Young man h/o asthma acute asthmatic attack treated with albuterol nebs - f/u now PFT will show
Obstructive defect (still has asthma dx)
35yo M paroxysmal non-prod cough >6months - no ohther sx - spirometry normal, no improvement with anti-histamine/cough meds
methacholine challenge test r/o asthma
woman in car factory SOB at work, worse at end of day, better at home, cxr normal
check peak flow at work AND home ** sen but not spec
Best way to tx patient with asthma
remove offending agent (PPI do not inc or dec sx of asthma)
Pt with asthma/eczema moves to new apt, asthma worse - with rug
remove rug, get plastic wraps for mattress, pillow etc
Asthma therapy: Intermittent (<2/wk, sx day, <2/mth sx night, FEV1>80%) tx?
no daily meds, rescue SABA
Asthma therapy: mild persistent (>2/wk, 2/month, FEV1 >80%)
- low dose ICS,
- cromolyn,
- leukotriene,
- theophylline
they will tempt you with LABA
Asthma therapy: Moderate persistent - daily sx, >5/month at night, FEV1 60-80
- low - med dose ICS +
2. LABA (no beta without inh steroid)
Severe persistent (sx continuous, freq at night, FEV1<60)
- high dose inh steroid +
- PO steroids with attempts to wean
high dose inhaled steroids have been associated with increased risk of pneumonia.
Leukotriene modifiers may be effective treatment for…
- mild persistent
- allow dose reduction of inhaled glucocorticoids in moderate and severe persistent asthma
- ASA-sensitive asthma
Pt w/ Vasomotor rhinitis, nasal polyps develops asthma. allergy to NSAIDS. dx?
dx: ASA sensitive asthma
tx: d/c asthma, start leukotriene inhib (monteleukast)
Pt with ASA sensitivity asthma. you can use
codeine based analgesic, sodium or choline slicylates, NO COX1 NSAIDS
Pt with shoulder pain takes ibuprofen - coupel hours later with SOB/wheezing
NSAID induced broncospasm
Pt w/ asthma on mild-mod dose of inhaled steroids with incomplete response. wtd?
start PO theophylline
50yo post viral URI several weeks ago with persistent cough, inc’d at night with chest tightness, no heartburn, recent neg cardiac w/u - PFT with mild obstruction - wtd
methacoline challenge test -
dx: post viral hypersensitivity - tx with inhaled steroid (budesonide once a day)
Mainstay maintenance therapy for asthma
inhaled steroids
30yo F non-prod cough for several months, no heart burn tob or wheeze, PFT normal, methacholine neg - wtf
check sputum for eosinophils - (non-asthmatic eosinophillic bronchitis)
Pt with athma on beta agonist still with wheeze
add inhaled steroid
Pt with severe asthma exacerbation hospitalized with iv steroid and beta agonist - upon d/c wtd
switch to tapering dose of oral steroid -> start inhaled steroid, beta agonist PRN
In addition to reduction of acute/chronic asthma sx what do inhaled steroids do?
reduction of progressive loss of lung fxn in adults and increased symptom free days
Pt with asthma on albuterol prn with nocturnal awakening with sx of asthma best medcation
start with inhaled steroids -> THEN add long acting beta agonist
increased mortality in asthma related to…
inc FEV1 responsiveness
Pt with asthma p/w acute exacerbation - ABG 7.46/34/70/94% - pt receives neb tx with albut, after 3rd tx pt with BS b/l but decreased - now RR>30, HR 130, ABG 7.38/46/70/92% wtd
INTUBATE PT
oxygenation goal in asthma
PaO2>60, SaO2>90%
Pt with asthma being treated with b2 agonist, inhaled steroid, montelukast still has sx, removes carpet/rug, no cat - SERUM IgE high - wtd?
add omalizumab (anti-IgE ab)
Asthmatic on b2 agonist prn, inhaled triamcinolone, almeterol and monteleukast - still with frequent exacerbation, does not like to go on logn term oral steroids - wtd
start tiotropium (spiriva)
Chronic cough
upper airway cough syndorme (post nasal drip), asthma, GERD, chronic bronchitis, ACEi, non asthamatic eosinophilic bronchitis*
Exercise induced asthma
sx peak 10-15 after stopping exc, resove in 30 min mainly in cold weather - Dx with excercise challenge test in cold air (drop FEV1 by 10-12%)
Exercise induced asthma tx
short-acting B2 agonist 30 min prior to excercise - if no effect then add cromyln Na+ …ppx = TID
If exercise induced asthma SOB on cromoyln
add inhaled steroids and monteleukast (3rd line)
Pt moves to minnesota (cold weather) - SOB in cold
start B agonist inhaler
Mechaism of cromyln Na+
mast cell stabilization (dec histamine release)
Pt with exercise induced asthma started on albuterol inhaler also wakes up at night 3x/wk to use albuterol inhaler… wtd?
start inhaled steroid + LABA
Allergic Bronco Pulmonary Asergillosis (ABPA)
colonization of upper airway with aspergillus i asthmatics - intense immed hypersensitive type rxn - inc IgE, +skin rxn to aspergillus Ag, serology +IgM, IgE, +eos, +brownish mucous plugs - > migratory pulm infiltrates (eos PNA)
pt with steroid dependent asthma p/w cough, wheezing BROWN mucous plugs - WBC: 15% eos, IgE>2000, CXR b/l infiltrates - steroids recently decreased - has parakeet
Allergic Broncopulm aspirgillosis (ABPA)
- incr eosinophils, incr IgE
Tx: incr steroids
Hypersensitivity pneumonitis
neg eos, normal IgE
Allergic angiitis of churg stauss
+eos, normal IgE
Loeffler’s syndrome (pulm eosinophilia)
+eos, inc IgE
Fungal ball in cavity ASX
monitor
Fungal ball in cavity with severe hemoptysis
surgery
Hypersensitivity Pneumonitis
farmer’s lung - fever, chills dyspnea after work everyday, works in grian elevator, pet bird (bird fancier’s lung), methotrexate or nitrofurantoin or works with A/C units
tx: remove the offending agent
Etio - hypersensitivity pneumonitis
inhaling organic dust with thermophilic actinomycetes - CXR GROUND GLASS APPEARANCE WITH NO EOSINOPHILS, +serum AB - BAL: CD8>CD4 (opposite of sarcoidosis –> LY,PHOCYTOSIS.)
remove offending agents, +steroids
Pt with dog, cat, 2 parakeets and pigeon - cough, progressive SOB, CXR reveals INTERSTITIAL/ALVEOLAR infiltrates (ground glass) - WBC no EOS - PFT restrictive
hypersensitivity pneumonitis (bird fancier lung)
70yo M chills, fever, non prod cough, pleuritis CP - recent acute pharygitis - received PCN/Amp w/o improvemnt - CXR with RLL infiltrate - BCtx neg, myoplasma,legionella ab neg - Dx?
Chlamydia pneumoniae
Psittacosis
disease asx in birds - complement fixation and serology useful in dx
Pt with asthma on fluticasone inhaler/oral steroids - montelukast added, oral steroids tapered down - pw cough, sob, wk righ thand/foot - 25% eos, IgE elevated - cxr bilateral dense pneumonic infiltrates
allergic angiitis/Churg strauss pneumonitis - tx with steroids
Latin american pw asthma, recent immigrant - recurrent cough despite B2 agonists - eos 20%, round infiltrates on CXR - ANCA neg, ANA neg
Loeffler’s syndrome - strongyloides infxn - tx with thiabendazole
35yo non-smoker F pw cough, no sputum, wheezing, nighttime sweats - h/o asthma - b/l crackles on exam - PPD neg, high eos in sputum high ESR
chronic eos PNA - long term steroid treatment
35yo construction worker p/w SOB, no wheeze, no CP, no hemoptysis no exp to toxic fumes - b/l crackles - diffuse opacities/GG - bronch with copius tan fluid - alveolar proteinosis
whole lung lavage - defective macrophages causing buildup of surfactant in lungs
COPD
dx: h/o chronic smoking dec FEV1/FVC<0.70
COPD Spirometry determines?
Severity of disease
Gold Criteria Mild COPD stageI
FEV1/FVC <70%, +FEV1 >80 …………………. tx = SABA prn, albuterol +/- ipratropium (SAMA(atrovent*)
Gold Criteria Mod COPD stageII
FEV1/FVC <70%, FEV1 < 80% …………. tx = SABA prn plus LABA (tiotropium(LAMA(spiriva)) +/-salmeterol (LABA(Serevent))+/- rehab
Gold Criteria Severe COPD stage III
FEV1 <50%, …….SABA, LABA + ICS (LABA/ICS combos: symbacort, advair, dulera, breo)
Gold Criteria very severe COPD stage IV
FEV1<30 %- use long term O2 therapy at least 15hrs/day. consider sx
… stage 4 w/ acute exacerbation should be treated like CAP
Major risk factor for COPD
Smoking
Main tx for COPD
bronchodil, antichol, supp O2 SaO2>90%
Therapy survival benefit for COPD
O2 supp at least 15hrs/day
Pt with COPD hypoxia on O2 therapy, PO2 signficantly improves - cause of low PO2 is…
V/Q mismatch
Bronchodilators do what for COPD
reduce hyperinflation, dec RV, improve sx and exc tolerance - DO NOT IMPROVE MORTALITY
Tiotropium is better than Ipratropium
True. reduces exacerbations, hospitalizations, lung hyperinflations. improves exercise tolerance. works by blocking muscarinic receptors. more potent than SABA. Superior to Salmeterol at 6 months.
Side effect of salmeterol/tioproprium
dry mouth
Pt with COPD, +tob - best way to preserve lung fxn
quit smoking
Inc’d mortality in COPD
decreased free fat mass. not bmi
Criteria for starting O2 on COPD pt
- PaO2 <55mmHg or O2 sat of 88%. PaO2<59mmHg or O2 sat >88% with evidence of Cor pulmonale, 3. erythrocytosis (Hct>55%)*
Role of inhaled steroids COPD
decrease exacerbations
Adv COPD pt Pulm rehab
DOES NOT improve FEV1, does NOT dec mortality, does improve sx, QOL, dec exacerbations, reduced dynamic hyperinflation, reduced healthcare utilization
Pulm rehab doesn’t work, still low exc tol, ABG 7.42, PO2 62, pCO2 48 - FEV120, b/l upper lobe emphysema
lung volume reduction surgery*
if FEV1 < 20 –> lung transplant (improved QOL, decreased mortality, improved increased BMI, decreased dyspnea)
Pt gets sick everytime he goes up a mountain to ski. He wants to go back next year…. what is he best advcie for prevention?
acetazolamide 24-48hours prior… watch out for syncope from decr BP.
Pt goes to colorado for skiing, on top of the mountain at 8000ft, he gets dyspnea and develops pulmonary edema. Paramedics start O2.. what is the most immediate step.??
bring him down to lower altitude……. pulm edema = leading cause of death with altitude sickenss - h/a, n/v/fatigue, dizzines PLUS SOB - 8000 to 12000 ft - tx descent, dexamethalazone, prev with acetazolamide or nifedipine
Thophylline decrease clearance by…
CHF, Liver dz, hypoxia, fever, cipro, erythro, OCP
Young woman h/o asthma on multiple meds and OCP c/o n/v - tachycardia/tremors . this is most likely related to her use of …
theophylline . OCP incr theophylline level which can cause MAT
COPD with Po2 60 pCO2 50 - exacerbation of COPD - PO2 55 and pCO2 60 - refuses intubation
BIPAP
50yo COPD p/w SOB,cough - awake but in severe distress, using accessory muslces - pCO2= 74, pO2= 50, pH= 7.18, HR 120, RR 36, BP =100/68. wtd?
intubate, mech ventillation……..
indications to intubate pt? pH<7.25, RR>35, HR>120. (positive secretions if close to criteria, hemoptysis counts.)
Mortality reduction COPD pt
flu vaccine
30yo M extensive bullous emphysema, CXR: b/l basal bullous cysts. which test would you do
check serum alpha 1 antitrypsin level
58yo F recurrent cough, foul smelling yellow sputum with hemoptysis, h/o PNA >1 yr ago - CXR: prominent cystic spaces in RLL, streaking opacites in the direction of bronchial tree( tram lines). dx? confirm?
dx bronchiectasis, confirm w/ high res CT scan. TIP = h/o PNA in the past
Bronchiectasis/sinusitis, infertiility, sinus inversus
Bronchiectasis/sinusitis, infertiility, sinus inversus…….
Dx Dyskinetic cilia syndrome/ Kartagener’s syndrome.
Screen by: inhaled nitric oxide test. Confirm by: bx of bronchi or sinus with video electron microscopy
22yo M recurrent PNA, bronchitis since childhood, no allergy or GERD, IgG electrophoresis nl, unable to have children. exam: slender body habitus and polyp in nose. clubbing (+), CXR:apical bullous changes. wtd next?
check sweat chloride. >60 = positive
dx : cystic fibrosis, inc’d ris kof endobronchial infxn with pseduomonas, staph, strep Pneum
Cystic Fibrosis tx?
- chest PT, abx (anti pseudom, topical tobramycin spray **, inhaled hypertonic saline, bronchodilators., 2. decrease sputum viscosity by human ribonuclease
- Treatment of severe bronchiectassis w/ bleed —> bronch artery embolization
Reduce decline in lung fxn with CF patient colonized with pseudomonas
Azithromycin (anti-inflamm effect)
35yo non-smoker, h/o RA, no asthma/allergies - p/w cough/dyspnea on exertion, recent viral URI. exam: JVD 6cms, no wheeze, CXR normal - PFT = severe obstruction w/ FEV1/FVC 0.6. DLCO 82%. No change after bronchodilator. alpha antitrypsin level normal
Bronchioitis obliterans - can occur after RA, carcinoid tumor, lung transplant
35yo F s/p radiation tx for breast CA p/w SOB, diffuse insp crackles - PaO2 52, PCO2 30, PFT dec DLCO, no response to abx
cryptogenic organizing PNA - dec DLCO, bx rapidly progressive organizing PNA or acute interstitial PNA - tx STEROIDS
Interstitial lung dz
sarcoid idiopathic Pulm Fibrosis hypersensitivity pneumonitis COP Allergic bronchopulm aspergillosis lyphogioleiomyomatosis Churg strauss
Sarcoid - indications for steroids
progressive pulm dz, eye involvement, CNS involvement, myocardial involvement, persistent hyperCA, disfiguring lesions
24yo F fever, pain, swelling both ankles (erythema nodsum - tender erythematous nodules - wtd
CXR r/o sarcoid - bil hilar LAD - no tx, adenopathy +parenchymal infiltrate - steroids if symptoms, diffuse infiltrates - no adenopathy - steroids if symptom
26yo F f/weakness, tenderness over legs - erythematous lesions, CXR b/l mediastinal adnopathy with infiltrates
BAL T4/T8 4:1, start steroids if eye involved, TB bx for non-caseating granulomas
All following elevated in sarcoidosis
Calcium in serum/urine, ACE, helper T cells
Idiopathic Pulm Fibrosis
insidous onset dry cough, gradual progressive dypsnea, cyanosis, clubbing, CXR diffuse infiltrative progess, reticular opacities, ground glass, honeycombing, PFT FEV1 low, FEV/FVC normal DLCO dec, BAL inc neutrophil
Tx: supportive care, O2 PRN, pneumovax, flu shot +- steroids
Asbestosis
Chronic exp x 10yr, lower lobe fibrosis, PFT - RESTRICTIVE patter - a/w mesothelioma, broncogenic CA, Pleural/diaphragm calcified plaques (no lung impairment)
Silicosis
chronic exp x 20 yrs (sandblasting, granite cutting) - upper lobe fibrosis with inc’d MTB incidence
EGG SHELL Calcifications with hilar LAD
58yo M SOB< CP, reporducible on palpation, 15lb wt loss over couple months, asbesthos exp - used to smoke, no BS in L base - pleural effusion L
mesothelioma/bronchogenic CA
Berylliosis
metal workers (computers, aerospace, electronics/lights b4 1950's) - can cause tracheobonchitis Bx - non-caseating granuloma A/w lung Ca
Male smoker with SOB, progressive - honeycomb on chest xray interstitial upper lung fields - PFT restrictive - BAL - langerhans cells (giant cells - also on bx
Langerhan cell granuloma/esoinophilic grnauloma/histiocytosis x
c/b - PTX
Tx: quit tobacco
Premenopausal woman on OCP with sudden SOB, CXR with PTX, honey comb appearance on CXR with CHYLOUS EFFUSION
lymphangioleiomyomatosis
Consequences of hyopxemia
pulm HTN, secondary erythrocytosis, exc intolerance, impaired mental fxn, precip sleep apena
COPD dx with pulm HTN - etiology?
hypoxia
Tx for pulm HTN pt with COPD
O2 tx keep SaO2 90-95%
Pulm arterial HTN
Idiopathic, hertiable, drug (Fen,fen), conn tissue d/o, HIV, portal HTN, congential heart dz
Pulm HTN from LH dz
systolic/diastolic dysfxn - valvular dz
Pulm HTN from lung dz/hypoxia
COPD, ILD, mixed restr/obst, chronic high altitude
Chronic throboembolic pulm HTN
PE of prox or distal pulm vasc
dx V/Q scan